Three different methods were used to compile the data necessary to develop the Start Healthy Feeding Guidelines, including: evaluating existing recommendations and guidelines from recognized organizations; using the ADA's evidence-based approach to analyze the literature; and conducting detailed analysis of the nutrient content of infants' and toddlers' diets compared to Dietary Reference Intakes (DRIs). This article explores the detailed process that led to the Start Healthy Expert Panel's conclusions and recommendations.
From even before birth until age two, what an infant or toddler eats may shape both short and long-term eating habits,1-5 and significantly influence his or her immediate and future health.6-8 The vast majority of parents are eager to feed their children the foods needed for healthy growth and development, and frequently look to a pediatric health professional for guidance about appropriate feeding practices. Yet, with the seemingly daily influx of pediatric health and nutrition research and information, pediatric professionals may find themselves in need of a reliable, up-to-date, concise and authoritative reference for providing dietary and feeding guidance to parents of infants and young children.
The American Dietetic Association (ADA) partnered with the Gerber Products Company to establish just such a reference, called the Start Healthy Feeding Guidelines for Infants and Toddlers. A panel of experts created these Guidelines using a three-part approach - the cornerstone of which was an ADA evidence-based literature review. Their goal was to integrate and update current infant and toddler feeding guidelines, and develop practical answers to parents' most common questions about feeding infants and toddlers. The related consumer-focused guidance is being developed and is anticipated to be released within the next year.
The ADA Evidence-Based Approach
As with evidence-based medicine, the two guiding principles of the ADA evidence-based approach are: 1) the establishment of a hierarchy of evidence that supports a recommendation, and 2) the recognition that clinicians and experts need to factor in a patient's values and preferences, as well as the values of society, when providing guidance about feeding infants and young children.9
The Start Healthy Expert Panel utilized the same seven-step ADA evidence-based approach used to prepare clinical guidelines, which include:
- Identifying a specific problem or area of uncertainty (in this project, areas for practical feeding advice);
- Formulating the problem as a research question;
- Developing a systematic search strategy and finding evidence;
- Selecting the relevant evidence;
- Evaluating and grading the evidence;
- Forming recommendations or making decisions based on the best available evidence;
- Summarizing and disseminating the findings.10
Most health care providers are familiar with the formal evidence analysis grading process used to create medical guidelines. The major difference in the ADA evidence-based approach and the well-known and most commonly used Centre for Evidence-Based Medicine (CEBM) method is the way in which research is classified, graded, and the evidence summarized (Steps 5 and 6). In the ADA method, evidence is classified as A (randomized controlled trials), B (cohort study), C (nonrandomized trial with concurrent or historical controls, case-control study, study of sensitivity and specificity of diagnostic test, or population-based descriptive study), D (cross-sectional study, case series, or case report), M (meta-analysis, systematic review, decision analysis, cost-benefit analysis, cost-effectiveness study), N (narrative review, consensus statement, consensus report), and X (expert opinion).
For purposes of an ADA evidence-based approach, review articles, consensus documents and statements of expert opinion are also classified as "evidence" and included in the evidence summary. The terms used for grading the evidence are reflected by Roman numerals I through IV as shown in Table 1. Conclusion statements with a Grade III or Grade IV indicate that the existing research base is limited and the related questions cannot be answered with a high degree of certainty. In particular those supported by Grade IV, expert opinion, are clear opportunities for pediatric researchers to address questions that have not previously been definitively answered.
Based on the best evidence, the Start Healthy Expert Panel developed the Start HealthyFeeding Guidelines recommendations, and the process used was summarized and published as "Development of the Start Healthy Feeding Guidelines for Infants and Toddlers" in the March 2004 issue of the Journal of the American Dietetic Association (JADA).11 The authors of the JADA article, which represent various areas of expertise, made up the core team responsible for conducting background work for the Expert Panel. These core team members were trained by the ADA in order to correctly utilize the ADA's tools (such as worksheets and evidence summaries), as well as their approach to evidence-based analysis. The foundation for the Start Healthy Feeding Guidelines was laid during meetings and conference calls between the core team and the Expert Panel, as they worked together to develop appropriate topic areas, discuss the evidence, and analyze the findings.
Methods Used to Create the Guidelines
In total, three different methods were used to compile the data necessary to develop the Start Healthy Feeding Guidelines: 1) evaluate existing recommendations and guidelines from recognized organizations, 2) evaluate the feeding and nutrition literature using the ADA evidence-based approach, and 3) conduct a detailed analysis of the nutrient content of infants' and toddlers' diets compared to Dietary Reference Intakes (DRIs). The preferred method was to use the ADA evidence-based approach. This systematic review of the research benefits from the clinical expertise of individual practitioners combined with the best clinical evidence for the benefit of patients.
Evaluate Existing Recommendations and Guidelines
In order to develop the Start Healthy Feeding Guidelines, the Expert Panel first identified specific areas where guidance for feeding infants and toddlers was needed. Areas to be evaluated for inclusion in the Guidelines were selected by the Panel based on the belief that they would be practical and useful, and that it was possible to create scientifically sound advice. Recommendations from academic and professional organizations, such as the American Academy of Pediatrics (AAP) and the ADA, and government agencies, including the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), were used as a starting point to determine what feeding guidance already existed.12, 13, 43, 61-62, 76, 80-182 The team then reviewed and summarized the twenty-nine topics relating to infant and toddler feeding addressed by the selected organizations, which are widely recognized for their pediatric nutrition expertise (Table 2). This review helped the Panel identify the topics to be included in the Start Healthy Feeding Guidelines.
For the topics to be included, recommendations and guidelines were evaluated for consistency among organizations. If the recommendations were consistent, then two main factors influenced the selection of topics for evidence analysis versus simply using the existing recommendations: 1) whether new information may be revealed in a certain area if an evidence-based approach were used, and 2) where practical advice was needed.
In certain areas, the existing recommendations were accepted as proposed by other organizations.12-79 These existing recommendations satisfactorily answer the questions found in Table 3.
Evaluate the Feeding and Nutrition Literature
As the core team examined existing recommendations for feeding, priority areas of focus emerged around which the Expert Panel developed research questions in reference to their relevance and importance to parents. One such area of focus, food transitions and developmental milestones, covers a broad range of feeding issues, from the initial introduction of solid foods into a previously all-milk or formula diet, to the gradual weaning to a varied diet, to the establishment of healthy eating habits that can last a lifetime. In order to examine the complex topic of food transitions, the Panel developed a framework with which to organize the research questions that included the topics of when, what, and how to feed infants and toddlers at each stage (Figure 1).
The question of when to feed infants and toddlers specific foods addressed the stages in oral readiness, gross and fine motor skill development, and gastrointestinal and renal maturation that must be achieved before a child can be introduced to each new food and texture. The question of what to feed addressed specific foods, nutrient requirements, and non-nutritional concerns such as food allergies and the role of physical activity for infants and toddlers. Introducing new foods and offering them a sufficient number of times, as well as the parent-child feeding relationship both factored into the question of how to feed. Figure 1 offers a quick reference of how each research question related to the broader questions parents might ask about when, what, and how to feed their child. The conclusion statements and grades for each of these questions can be found in the March 2004 issue of JADA.183
Evaluate the Nutrient Needs of Infants and Toddlers
The third methodology used to support the Guidelines' development included the evaluation of the nutrient needs of infants and toddlers. To answer the research question "what are the nutrient requirements of infants and toddlers?" the Expert Panel turned to the Dietary Reference Intakes (DRIs) from the Food and Nutrition Board, Institute of Medicine/Health Canada, which identify all the essential nutrients for healthy growth and development of infants and toddlers.28-31 Supplementing this information with biochemical or clinical evidence of nutrient deficiency among infants and toddlers helped the Panel identify which nutrients need to be especially emphasized to parents.
Infants present a special circumstance when determining the type and quantity of foods to feed, since a portion of their diet may consist of breast milk, for which specific intakes may be difficult to judge. To establish how much energy and nutrients infants require from the complementary foods they are fed, the Expert Panel subtracted the nutrients supplied by an average intake of human milk from recommended intake levels, which is comparable to methods employed by the WHO.184 The Panel determined how much energy infants 6 to 12 months old need from complementary foods by observing the difference between how much energy they might obtain from milk and their estimated energy requirements (EER) from the DRI. A similar process was used to determine which nutrients needed to be supplied by complementary foods. For children aged 6 to 24 months at the 50th percentile for weight from the CDC growth charts,14,185 the Panel calculated how much dietary energy is needed to support growth and a healthy energy balance.
To aid parents in making sure that their infants or toddlers receive all the nutrients they need, registered dietitians prepared sample menus specifically for each of the following age categories: infants 6 to 8 and 9 to 12 months of age, and toddlers 12 to 17 and 18 to 24 months of age. To analyze the nutrient content of these menus, the dietitians utilized software developed by the Nutrition Coordinating Center, University of Minnesota, Minneapolis.186 The menus created took into consideration the AAP's recommendations for the appropriate age and amounts to offer juice and whole cow's milk to children.12,187 The areas where it was vital to meet nutrient goals were identified, as were specific foods that may help meet these special nutrient needs. After assessing which nutrients are needed for healthy growth and development, it was clear to the Panel that high-calorie, low-nutrient foods, such as sweetened beverages and candy, have little or no place in an infant's or toddler's diet.
Converting the Data into Guidelines for Parents and Practitioners
With all of the articles and recommendations summarized and conclusion statements made, the Expert Panel set about forming the practical suggestions for parents, shaping their statements with regard to typical questions that parents might ask regarding feeding their infant or toddler, such as:
"When do I feed my baby?"
"What foods do I feed my baby?"
"How do I feed my baby?"
A near-term task is to determine the best way to make the messages of the Start Healthy Feeding Guidelines, such as the sample menus and developmental milestones and eating skills charts, available to both professionals and parents. Message testing with both parents and pediatric professionals will help to ensure that the materials are useful and being presented in the most helpful and practical way. All the components that make up the entire evidence analysis, from the initial worksheets to the conclusion statements, will surely become an important resource for researchers and practitioners.
The core team had important suggestions for groups that may elect to use an evidence-based approach in formulating guidelines for a specific population or group of people. These included the importance of training in evidence-based analysis for everyone involved in the process (not just the evidence analysts), and that a team should allow ample time to conduct literature searches, sort their findings, and discuss different facets of the process. Other suggestions included looking to additional experts for help and input, such as a librarian with an understanding of the topic at hand, and experts in fields not represented by the expert group conducting the evidence analysis. Finally, the team stressed the importance of ensuring consistency when completing worksheets and summaries through a system of checks and balances among the evidence analysts.
The team responsible for developing the Start Healthy Feeding Guidelines for Infants and Toddlers took great care to examine the topic of feeding recommendations from every angle, in order to generate practical guidance for both pediatric professionals and parents. Using the ADA's evidence-based review process allowed the team to mine the wisdom from scores of research and review articles and expert opinion statements to reach conclusions on the many different facets of feeding infants and toddlers. Supplementing this process with a review and synthesis of existing literature and a scientific analysis of nutritional needs resulted in a well-rounded, well-informed data set from which the Expert Panel drew the Guidelines, which can be found in the accompanying article in this journal.183 The process of evidence analysis also clearly identified areas where additional research is needed to truly address all the questions.
Examining the process followed to arrive at the Start Healthy Feeding Guidelines shows how careful methodology resulted in sound and practical suggestions for healthy feeding. Knowing that the Guidelines were developed using this rigorous process should assure pediatric health care providers that the information provided to consumers is truly the best advice available, based on the existing research.
Dr Esther Myers is Director, Scientific Affairs and Research at the American Dietetic Association. Among other research related activities she oversees the process used to analyze the evidence for evidence-based guides for Medical Nutrition Therapy that is provided by registered dietitians. She is an international speaker on the application of evidence-based practice.
- Gerrish CJ, Mennella JA: Flavor variety enhances food acceptance in formula-fed infants. Am J Clin Nutr 73:1080-85, 2001.
- Mennella JA, Jagnow CP, Beauchamp GK: Prenatal and postnatal flavor learning by human infants. Pediatrics 107:E88, 2001.
- Birch LL, Martin DW: I don't like it, I never tried it: effects of exposure to food on two-year-old children's food preferences. Appetite 4: 323-31, 1982.
- Sullivan SA, Birch LL: Infant dietary acceptance of solid foods. Pediatrics 93:271-7, 1994.
- Skinner JD, Carruth BR, Bounds W, Ziegler P, Reidy K: Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ and Behav 34:310-315, 2002.
- Steinmetz KA, Potter JD: Vegetables, fruit, and cancer prevention: a review. J Am Diet Assoc 96:1027-39, 1996.
- Van Duyn MA, Pivonka E: Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: selected literature. J Am Diet Assoc 100:1511-21, 2000.
- Specker B: Nutrition influences bone development from infancy through toddler years. J Nutr 134:691S-5S, 2004.
- Guyatt GH, Haynes RB, Jaeschke RZ, Cood DJ, Green L, Naylor CD, Wilson MC, Richardson WS: Users' guides to the medical literature: XXV. Evidence-based medicine: Principles for applying the Users' Guides to patient care. Evidence-based medicine working group. J Am Med Assoc 284:1290-6, 2000.
- Myers EF, Splett PL: Research in evidence-based practice. In: Monsen ER, ed. Research: Successful Approaches. Chicago: American Dietetic Association 164-84, 2003.
- Pac S, McMahon K, Ripple M, Reidy K, Ziegler P, Myers E: Development of the Start Healthy Feeding Guidelines for Infants and Toddlers. J Am Diet Assoc 104:455-67, 2004.
- Kleinman RE: American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition Handbook. Fourth Edition. Elk Grove Village, IL: American Academy of Pediatrics, 1998.
- Brown K, Dewey K, Allen L. Complementary Feeding of Young Children in Developing Countries: A Review of Scientific Knowledge. Geneva, Switzerland: World Health Organization, 1998.
- Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academy Press, 2002.
- Lebenthal E: Impact of digestion and absorption in the weaning period on infant feeding practices. Pediatrics 75:207-213, 1985.
- Montgomery RK, Grand RJ: Gastrointestinal development: implications for infant feeding. In: Walker WA, Watkins JB, Duggan C, Becker BC, eds. Nutrition in Pediatrics. Hamilton, Ontario: BC Becker, 2003.
- Montgomery RK, Mulberg AE, Grand RJ: Development of the human gastrointestinal tract: Twenty years of progress. Gastroenterology 116:702-31, 1999.
- Ziegler EE: Milks and formulas for older infants. J Pediatr 117:S76-9, 1990.
- Ziegler E, Jiang T, Romera E, Vinco A, Frantz J, Nelson S: Cow's milk and intestinal blood loss late in infancy. J Pediatr 135:720-6, 1999.
- Tianan J, Jeter J, Nelson S, Ziegler E: Intestinal blood loss during cow milk feeding in older infants. Arch Pediatr Adolesc Med 154:673-8, 2000.
- Ziegler E, Fomon S, Nelson S, Rebouche C, Edwards B, Rogers R, Lehman L: Cow milk feeding in infancy: Further observations on blood loss from the gastrointestinal tract. J Pediatr 116:11-18, 1990.
- Fuchs G, DeWier M, Hutchinson S, Sundeen M, Schwartz S, Suskind R: Gastrointestinal blood loss in older infants: Impact of cow milk versus formula. J Pediatr Gastroenterol Nutr 16:4-9, 1993.
- Ernst JA, Brady MS, Rickard KA: Food and nutrient intake of 6- to 12-month-old infants fed formula or cow milk: A summary of four national surveys. J Pediatr 117:S86-100, 1990.
- Marlin DW, Picciano MF, Livant EC: Infant feeding practices. J Am Diet Assoc 77:668- 76, 1980.
- Fomon SJ: Feeding normal infants: Rationale for recommendations. J Am Diet Assoc 101:1002-5, 2001.
- Fomon SJ, Ziegler EE: Renal solute load and potential renal solute load in infancy. Pediatrics 134:11-4, 1999.
- Fomon SJ: Potential renal solute load: Considerations relating to complementary feedings of breastfed infants. Pediatrics 106:1284-5, 2000.
- Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybedenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2001.
- Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press, 1997.
- Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press, 1998.
- Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press, 1997.
- Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR. April 3, 1998.
- Centers for Disease Control and Prevention. Pediatric Nutrition Surveillance data—Growth and anemia indicators by race/ethnicity and age, 2001.
- Gartner LM, Greer FR and the Section on Breastfeeding and Committee on Nutrition: Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 111:908-10, 2003.
- Clark JE, Clemints RL, Guddemi M, Morgan DW, Pica R, Pivarnik JM, Rudisill M, Small E, Virgilio SJ: "Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years." Reston, VA: National Association for Sport and Physical Education, 2002.
- Shelov S: American Academy of Pediatrics Caring for Your Baby and Young Child—Birth to Age 5. New York, NY: Bantam Books, 1998.
- American Academy of Pediatrics Committee on Public Education: Policy statement: Children, adolescents and television. Pediatrics 107:423-426, 2001.
- American Academy of Pediatrics Committee on Injury and Poison Prevention: Injuries associated with infant walkers. Pediatrics 108:790-2, 2001.
- American Academy of Pediatrics Committee on Sports Medicine: Infant exercise programs. Pediatrics 82:800, 1988.
- American Academy of Pediatrics Committee on Sports Medicine and Fitness and Committee on School Health: Policy statement: Physical fitness and activity in schools (RE9907). Pediatrics 105: 1156-7, 2000.
- American Academy of Pediatrics. Establishing good sleep habits. 1999. Available at: http://www.medem.com/MedLB/article_detaillb.cfm?article_
ID=ZZZYCAGNH4C⊂_cat=14. Accessed April 27, 2004.
- Abbott AL, Bartlett DJ: Infant motor development and equipment use in the home. Child Care Health Dev 27:295-306, 2001.
- American Heart Association Scientific Statement. Cardiovascular Health in Childhood: A statement for health professionals from the Committee on Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of the Council on Cardiovascular Disease in the Young, American Heart Association. Circulation 106:143-60, 2002.
- American Medical Association. Sleep and your 1-3 month old. 1997.
Available at: http://www.medem.com/search/article_display.cfm?path=\\TANQUERAY\M_ContentItem&mstr=/M_ContentItem/ ZZZEM8KW59C.html&soc=AMA&srch_typ=NAV_SERCH. Accessed April 27, 2004.
- American Public Health Association Resolution on Overweight in Childhood. 2001. Available at: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction=view&id=252
- Patrick K, Spear B, Holt K, Sofka D. Bright Futures in Practice: Physical Activity. Arlington, VA: National Center for Education in Maternal and Child Health. 2001. Available at: http://www.brightfutures.org/physicalactivity/pdf/main.html
- Certain L, Kahn R: Prevalence, correlates and trajectory of television viewing among infants and toddlers. Pediatrics 109:634-42, 2002.
- Garrett M, McElroy AM, Staines A: Locomotor milestones and babywalkers: Cross sectional study. Br Med J 324:1494, 2002.
- Kohl H, Hobbs K: Development of physical activity behaviors among children and adolescents. Pediatrics 101:549-54, 1998.
- McEwan MH, Dihoff RE, Brosvic GM: Early infant crawling experience is reflected in later motor skill development. Percept Mot Skills 72:75-9, 1991.
- National Institute of Child Health and Human Development: SIDS: "Back to Sleep" Campaign. Babies sleep safest on their backs: Reduce the risk of sudden infant death syndrome. October 2002. Available at: http://www.nichd.nih.gov/sids/sleep_risk.htm. Accessed April 27, 2004.
- Ogden C, Troiano R, Briefel R, Kuczmarski R, Flegal K, Johnson C: Prevalence and trends in overweight among US children and adolescents, 1999-2000. J Am Med Assoc 288:1728-32, 2002.
- Parsons TJ, Power C, Logan S, Summerbell CD: Childhood predictors of adult obesity: A systematic review. Int J Obes Relat Metab Disord 23(suppl 8): S1-S107, 1999.
- Power C, Parsons T: Nutrition and other influences in childhood as predictors of adult obesity. Proc Nutr Soc 59:267-72, 2000.
- Salls JS, Silverman LN, Gatty: The relationship of infant sleep and play positioning to motor milestone achievement. Am J Occup Ther 56:577-580, 2002.
- Siegel AC, Burton RV: Effects of baby walkers on motor and mental development in human infants. J Dev Behav Pediatr 20:355-61, 1999.
- US Department of Health and Human Services: The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.
- Wells JC, Ritz P: Physical activity at 9-12 months and fatness at 2 years of age. Am J Human Biol 13:384-9, 2001.
- Wells JC, Stanley M, Laidlaw AS, Day JM, Davies PS: The relationship between components of infant energy expenditure and childhood body fatness. Int J Obes Relat Metab Disord 20:848-53, 1996.
- American Academy of Pediatrics: New Mother's Guide to Breastfeeding. New York: Bantam Books, 2002.
- American Dietetic Association: Nutrition standards for childcare programs. J Am Diet Assoc 99:981-8, 1999.
- Story M, Holt K, Sofka D, Clark EM: Bright Futures in Practice: Nutrition. Arlington, VA: National Center for Education in Maternal and Child Health, 2002.
- Oesterreich L: Feeding infants. In: Oesterreich L, Holt B, Karas S, Iowa family child care handbook [Pm 1541] (pp. 183-188). Ames, IA: Iowa State University Extension, 1995. Available at: www.nncc.org/Nutrition/feed.infants.html. Accessed April 27, 2004.
- USDA Food and Nutrition Service. (FNS-258). Feeding Infants: A Guide for Use in the Child Nutrition Programs.
- Ogundele MO: Techniques for the storage of human breast milk: implications for anti-microbial functions and safety of stored milk. Eur J Pediatr 159:793-7, 2000.
- Disney G: University of Tennessee Institute of Agriculture, USDA Safe Food for Baby, 1997.
Available at: http://www.utextension.utk.edu/spfiles/sp495.pdf. Accessed April 27, 2004.
- Department of Health and Human Services Office on Women's Health. Breastfeeding made easier at home and work: Storing Breast Milk. Available at: http://www.4woman.gov/Breastfeeding/print-bf.cfm?page=237. Accessed April 27, 2004.
- World Health Organization. Infant and young child nutrition—global strategy for infant and young child feeding. April 16, 2002. Available at: http://www.who.int/gb/EB_WHA/PDF/WHA55/ea5515.pdf. Accessed April 27, 2004.
- Environmental Protection Agency. How lead affects the way we live and breath.
Available at: http://www.epa.gov/air/urbanair/lead/main.html. Accessed April 27, 2004.
- Agency for Toxic Substances and Disease Registry. The child as susceptible host: a developmental approach to pediatric environmental medicine. Available at: http://www.atsdr.cdc.gov/HEC/CSEM/pediatric/susceptible.html#host. Accessed April 27, 2004.
- Centers for Disease Control. About childhood lead poisoning. Available at: http://www.cdc.gov/nceh/lead/about/about.htm. Accessed April 27, 2004.
- US Food and Drug Administration, Center for Food Safety and Applied Nutrition: Rationale for issuance of revised advisory on methylmercury and fish consumption, 2001. Available at: http://www.cfsan.fda.gov/~acrobat/hgadv4.pdf. Accessed April 27, 2004.
- Environmental Protection Agency. Tips to protect children from environmental risks. Available at: http://yosemite.epa.gov/ochp/ochpweb.nsf/content/tips.htm. Accessed April 27, 2004.
- Keyser SL. Nitrates and nitrites. June 1997. Available at: http://extoxnet.orst.edu/faqs/safedrink/nitrates.htm. Accessed May 4, 2004.
- Skipton S, Hay D. Drinking water: nitrate and methemoglobinemia. Nebraska Cooperative Extension G98-1369. July 1995. Available at: http://www.ianr.unl.edu/pubs/water/g1369.htm. Accessed April 27, 2004.
- Pelto G, Levitt E, Thairu L: Improving feeding practices: current patterns, common constraints and the design of interventions. Food Nutr Bull 24:45-82, 2003.
- Cooper RL, Cooper MM: Red pepper-induced dermatitis in breast-fed infants. Dermatology 193:61-2, 1996.
- Khan ME: Breast-feeding and weaning practices in India. Asia-Pac Popul J 5:71-88, 1990.
- Chinese Nutrition Society: Dietary Guidelines—Recommendations for particular groups of people-Infants. Available at: http://www.cnsoc.org/sszn1e0.htm. Accessed April 27, 2004.
- Halverson HM: An experimental study of prehension in infants by means of systematic cinema records. Genet Psychol Monogr 10:107-286, 1931.
- Gessell A, Ilg F: Feeding behavior of infants: a pediatric approach to the mental hygiene of early life. Philadelphia, PA: J. B. Lippincott Company, 1937.
- Gesell A: The first five years of life: a guide to the study of the preschool child. New York, NY: Harper & Brothers, 1940.
- Gesell A, Ilg F, Ames LB, Rodell JL: Infant and child in the culture of today: the guidance of development in home and nursery school. New York: Harper & Row Publishers, 1974.
- Illingworth RS, Lister J: The critical or sensitive period, with special reference to certain feeding problems in infants and children. J Pediatr 65:839-48, 1964.
- Cohen MA, Gross PJ: The developmental resource: behavioral sequences for assessment and program planning volume 1. New York, NY: Grune & Stratton, 1979.
- Pridham KF: Feeding behavior of 6- to 12-month-old infants: assessment and sources of parental information. J Pediatr 117:S174-80, 1990.
- Meyer PG: Tongue and lip and jaw differentiation and its relationship to orofacial myofunctional treatment. Int J Orofacial Myology 26:44-52, 2000.
- Morris SE, Klein MD: Pre-feeding skills, 2nd edition. San Antonio, TX: Therapy Skill Builders, 2000.
- Tamura F, Chigira A, Ishii H, Nishikata H, Mukai Y: Assessment of the development of hand and mouth coordination when taking food into the oral cavity. Int J Orofacial Myology 26:33-43, 2000.
- Carruth BR, Skinner JD: Feeding behaviors and other motor development in healthy children (2-24 months). J Am Col Nutr 21:88-96, 2002.
- Ayano R, Tamura F, Ohtsuka Y, Mukai Y: The development of normal feeding and swallowing: Showa University study of the feeding function. Int J Orofacial Myology 26:24-32, 2000.
- Beal VA: On the acceptance of solid foods, and other food patterns, of infants and children. Pediatrics 20:448-57, 1957.
- Bu'Lock F, Woolridge MW, Baum JD: Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and pre-term infants. Dev Med Child Neurol 32: 669-78, 1990.
- Chigira A, Omoto K, Mukai Y, Kaneko Y: Lip closing pressure in disabled children: a comparison with normal children. Dysphagia 9:193-198, 1994.
- Gisel EG: Effect of food texture on the development of chewing of children between six months and two years of age. Dev Med Child Neurol 33:69-79, 1991.
- Hunt L, Lewis D, Reisel S, Waldrup L, Wooster A, Donna M: Age norms for straw-drinking ability. Infant-Toddler Intervent 10:1-8, 2000.
- Schulze PA, Harwood RL, Schoelmerich A: Feeding practices and expectations among middle-class Anglo and Puerto Rican mothers of 12-month-old infants. J Cross-Cultural Psychol 32:397-406, 2001.
- Tulve NS, Suggs JC, McCurdy T, Cohen HE, Moya J: Frequency of mouthing behavior in young children. J Expo Anal Environ Epidemiol 12:259-64, 2002.
- Vestergaard M, Obel C, Henriksen TB, Sorensen HT, Skajaa E, Ostergaard J: Duration of breastfeeding and developmental milestones during the latter half of infancy. Acta Paediatr 88:1327-32, 1999.
- Young B, Drewett R: Eating behaviour and its variability in 1-year-old children. Appetite 35:171-7, 2000.
- Wolff PH: The serial organization of sucking in the young infant. Pediatrics 42:943-56, 1968.
- Wright JT: Normal formation and development defects of the human dentition. Pediatr Clin North Am 47:975-1000, 2000.
103 Green JR, Moore CA, Ruark JL, Rodda PR, Morvee WT, VanWitzenburg MJ: Development of chewing in children from 12 to 48 months: longitudinal study of EMG patterns. J Neurophysiol 77:2704-16, 1997.
- Lundy B, Field T, Carraway K, Hart S, Malphurs J, Rosenstein M, Palaez-Nogueras M, Coletta F, Ott D, Hernandez-Reif M: Food texture preferences in infants versus toddlers. Early Child Dev Care 146:69-85, 1998.
- Northstone K, Emmett P, Nethersole F: The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. J Hum Nutr Diet 14:43-54, 2001.
- Sheppard JJ, Mysak ED: Ontogeny of infantile oral reflexes and emerging chewing. Child Dev 55:831-43, 1984.
- Bardare M, Vaccari A, Allievi E, Brunelli L, Coco F, de Gaspari GC, Flauto U: Influence of dietary manipulation on incidence of atopic disease in infants at risk. Ann Allergy 71:366- 71, 1993.
- Zeiger RS, Heller S, Mellon MH, Forsythe AB, O'Connor RD, Hamburger RN, Schatz M: Effect of combined maternal and infant allergen avoidance on development of atopy in early infancy: a randomized study. J Allergy Clin Immunol 84:72- 89, 1989.
- Høst A, Koletzko B, Dreborg S, Muraro A, Wahn U, Aggett P, Bresson J-L, Hernell O, Lafeber H, Michaelsen KF, Micheli J-L, Rigo J, Weaver L, Heymans H, Strobel S, Vandenplas Y: Dietary products used in infants for treatment and prevention of food allergy. Joint statement of the European Society for Paediatric Allergology and Clinical Immunology and European Society for Paediatric Gastroenterology, Hepatology and Nutrition. Arch Dis Child 81: 80-4, 1999.
- Businco L, Bruno G, Giampietro PG, Ferrara M: Is prevention of food allergy worthwhile? J Investig Allergol Clin Immunol 3:231-6, 1993.
- Halken S, Host A: Prevention. Curr Opin Allergy Clin Immunol 1:229-36, 2001.
- Chandra RK: Food allergy. Indian J Pediatr 69:251-5, 2002.
- Foucard T: Development of food allergies with special reference to cow's milk allergy. Pediatrics 75:177-81, 1985.
- Koletzko B: Complementary foods and the development of food allergy. Pediatrics 106:1285, 2000.
- Mofidi S: Nutritional management of pediatric food hypersensitivity. Pediatrics 111: 1645-53, 2003.
- American Academy of Allergy Asthma & Immunology: The Allergy Report. 2000. Available at: http://www.theallergyreport.org/reportmain.html. Accessed April 29, 2004.
- Arshad SH: Food allergen avoidance in primary prevention of food allergy. Allergy 56:113-6, 2001.
- Wolfe SP. ‘Prevention programmes'—A dietetic minefield. Eur J Clin Nutr 49:S92-9, 1995.
- Sampson H: Food Allergy. J Am Med Assoc 278:1888-94, 1997.
- Formanek R: Food allergies—When food becomes the enemy. FDA Consumer Magazine July-August, 2001.
- Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC: Maternal feeding practices and childhood obesity: A focus group study of low-income mothers. Arch Pediatr Adolesc Med 152:1010-14, 1998.
- Black M, Siegel E, Abel Y, Bentley ME: Home and videotape intervention delays early complementary feeding among adolescent mothers. Pediatrics 107:67, 2001.
- Bober SJ, Humphry R, Carswell HW, Core AJ: Toddlers' persistence in the emerging occupations of functional play and self feeding. Am J Occup Ther 1:369-76, 2001.
- Hagekull B, Dahl M: Infants with and without feeding difficulties: maternal experiences. Int J Eat Disord 6:83-98, 1987.
- Humphry R, Thigpen-Beck B: Caregiver role: ideas about feeding infants and toddlers. Occup Ther J Res 17:237-63, 1997.
- Klesges RC, Coates TJ, Brown G, Sturgeon-Tillisch J, Moldenhauer-Klesges LM, Holzer B, Woolfrey J, Vollmer J: Parental influences on children's eating behavior and relative weight. J Appl Behav Anal 16:371-8, 1983.
- Kramer MS, Barr RG, Leduc DG, Boisjoly C, McVey-White L, Pless IB: Determinants of weight and adiposity in the first year of life. J Pediatr 106:10-4, 1985.
- Mogan J: Parental weight and its relation to infant feeding patterns and infant obesity. Int J Nurs Stud 23:255-64, 1986.
- Morris SS, Farrier SC, Rogers CS, Taper LJ: Feeding behaviors, food attitudes, and body fatness in infants. J Am Diet Assoc 80:330-4, 1982.
- Morris SS, Rogers CS, Taper LJ: Care-giving behaviors in feeding 3-, 13-, and 23-month-old infants. Nutr Behav 1:147-56, 1983.
- Omar MA, Coleman G, Hoerr S: Healthy eating for rural low-income toddlers: caregivers' perceptions. J Community Health Nurs 18:93-106, 2001.
- Scaglioni S, Agostoni C, DeNotaris R, Radaelli G, Radice N, Valenti M, Giovannini M, Riva E: Early macronutrient intake and overweight at five years of age. Int J Obes 24:777-81, 2000.
- Birch LL: Psychological influences on the childhood diet. J Nutr 128:407S-10S, 1998.
- Brayden RM, Poole SR: Common behavioral problems in infants and children. Primary Care 22:81-97, 1995.
- Christophersen ER, Hall CL: Eating patterns and associated problems encountered in normal children. Issues Compr Pediatr Nurs 3:1-16, 1978.
- Dettwyler KA: Styles of infant feeding: parental/caretaker control of food consumption in young children. Am Anthropol 91:696-703, 1989.
- Mentro AM, Steward DK, Garvin BJ: Infant feeding responsiveness: a conceptual analysis. J Adv Nurs 37:208-16, 2002.
- Satter E: The feeding relationship. In: Kessler DB, Dawson P, eds. Failure to thrive and pediatric undernutrition: a transdisciplinary approach. Baltimore, MD: Paul H. Brookes Publishing, 1999.
- Zeitlin M: Nutritional resilience in a hostile environment: positive deviance in child nutrition. Nutr Rev 49:259-68, 1991.
- Darbyshire P: Infant feeding: fussy eaters. Nurs Times 83:57-8, 1987.
- Daws D: Perils of intimacy. J Child Psychother 23:179-99, 1997.
- Daws D: Family relationships and infant feeding problems. Health Visitor 67:162-4, 1994.
- Finney JW: Preventing common feeding problems in infants and young children. Pediatr Clin North Am 33:775-788, 1986.
- Goldberg S: Social competence in infancy: A model of parent-infant interaction. Merrill-Palmer Q 23:163-77, 1977.
- Margiotta P: Infant feeding: the food of love. Community Outlook Feb 8:6-11, 1989.
- McBean L, Miller G: Enhancing nutrition of America's youth. J Am Coll Nutr 18:563-71, 1999.
- Mogan J: Prevention of childhood obesity. Issues Compr Pediatr Nurs 9:33-8, 1986.
- Nutt HH: Infant nutrition and obesity. Nurs Forum 18: 131-56, 1979.
- Romeo S: Transitioning to table foods: the parent offers and the child eats…sometimes. Adv Nurse Practs 9:63-8, 2001.
- Satter E: Feeding dynamics: helping children to eat well. J Pediatr Health Care 9: 178-84, 1995.
- Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC: The challenge of preventing and treating obesity in lowincome, preschool children: perceptions of WIC health care professionals. Arch Pediatr Adolesc Med 156:662-8, 2002.
- Wright P: Learning experiences in feeding behavior during infancy. J Psychosom Res 32:613-9, 1988.
- Livingstone B: Healthy eating in infancy. Professional Care of Mother and Child 7:9-11, 1997.
- Schmitt B: Infants who do not sleep through the night. J Dev Behav Pediatr 2:20-3, 1981.
- Mennella J, Beauchamp G: Mothers' milk enhances the acceptance of cereal during weaning. Pediatr Res 41:188-192, 1997.
- Sullivan SA, Birch LL: Infant dietary acceptance of solid foods. Pediatrics 93:271-7, 1994.
- Owles EW, Hitchcock NE, Gracey M: Feeding patterns of Australian infants: birth to one year. Hum Nutr: Appl Nutr 36: 202-7, 1982.
- Coutts A: Nutrition and the life cycle 2: infancy and weaning. Br J Nurs 9:2205-16, 2000.
- Rozee E: Concepts in infant nutrition. The Canadian Nurse 72:18-21, 1976.
- Slattery JS: Nutrition for the normal healthy infant. Am J Maternal Child Nurs 2:105-112, 1977.
- Hill AS, Bishop S, Malloy MH: Introduction of solid foods to African American and Anglo American low-birth-weight and full-term infants. ABNF J 6:118-24, 1995.
- Underwood BA, Hofvander Y: Appropriate timing for complementary feeding of the breastfed infant: a review. Acta Paediatr Scand 294:1-32, 1982.
- Kramer MS, Kakuma R: Optimal duration of exclusive breastfeeding (Cochrane Review) In: The Cochrane Library, Issue 2, 2004.
164 Vahlquist B: Supplementary feeding of infants and young children. Bibliotheca Nutritio Et Dieta 18:202-14, 1973.
- Meer PA: Update on feeding babies solid food. J Pediatr Health Care 12:152-3, 1998.
- McConahy KL, Smicklas-Wright H, Birch LL, Mitchell DC, Piccano MF: Food portions are positively related to energy intake and body weight in early childhood. J Pediatr 140:340-7, 2002.
- Reau NR, Senturia YD, Lebailly SA, Kaufer K, Christoffel: Infant and toddler feeding patterns and problems: normative data and a new direction. Dev Behav Pediatr 17:149-53, 1996.
- Pearce C: Food intake and meal patterns of one year old infants. Appetite 29:201-12, 1997.
- United States Department of Agriculture Food and Nutrition Service: FNS-305. Blocks for Fun and Healthy Meals. A menu planner for the child and adult care food program. 2000. Available at: http://www.fns.usda.gov/tn/Resources/buildingblocks.html. Accessed May 4, 2004.
- Skinner JD, Carruth BR, Bounds W, Ziegler P, Reidy K: Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ and Behav 34: 310-5, 2002.
- Skinner JD, Carruth BR, Bounds W, Ziegler P: Children's food preferences: A longitudinal analysis. J Am Diet Assoc 102:1638-47, 2002.
- Mennella JA, Beauchamp G: Flavor experiences during formula feeding are related to preferences during childhood. Early Hum Dev 68:71-82, 2002.
- Gerrish CJ, Mennella JA: Flavor variety enhances food acceptance in formula-fed infants. Am J Clin Nutr 73:1080-85, 2001.
- Mennella J: Early flavor experiences: research update. Nutr Rev 56:205-11, 1998.
- Birch LL: What kind of exposure reduces children's food neophobia? Looking vs. tasting. Appetite 9:283-9, 1987.
- Birch LL, Gunder L, Grimm-Thomas K, Laing DG: Infants' consumption of a new food enhances acceptance of similar foods. Appetite 30:283-95, 1998.
- Birch LL: Development of food acceptance patterns in the first years of life. Proc Nutr Soc 57:617-624, 1998.
- Carruth BR, Skinner J, Houck K, Moran J III, Coletta F, Ott D: The phenomenon of "picky eater": a behavioral marker in eating patterns of toddlers. J Am Col Nutr 17:180-6, 1998.
- Miller AM, Harwood RL: The cultural organization of parenting: change and stability of behavior patterns during feeding and social play across the first year of life. Parenting: Sci Pract 2:241-72, 2002.
- Schulze PA, Harwood RL, Schoelmerich A, Leyendecker B: The cultural structuring of parenting and universal developmental tasks. Parenting: Sci Pract 2:151-78, 2002.
- Avery A, Baxter A: Change to cup: An audit to determine parental awareness and practices in changing from bottle to cup. J Hum Nutr Diet 14:217-23, 2001.
- Birch LL, Fisher JA: Appetite and eating behavior in children. Pediatr Clin North Am 42:931-53, 1995.
- Butte N, Cobb K, Dwyer J, Graney L, Heird W, Rickard K: The Start Healthy Feeding Guidelines for Infants and Toddlers. J Am Diet Assoc 104:442-454, 2004.
- Dewey KG, Brown KH: Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Food Nutr Bull 24:5-28, 2003.
- Kuczmarksi RJ, Ogden CL, Gummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL: CDC Growth Charts: United States. Advance Data from Vital and Health Statistics of the Centers for Disease Control and Prevention/National Center for Health Statistics: Number 314 December 4, 2000 (revised).
- Schakel SF, Sievert YA, Buzzard IM: Sources of data for developing and maintaining a nutrient database. J Am Diet Assoc 88:1268-71, 1988.
- Committee on Nutrition: The use and misuse of fruit juice in pediatrics. Pediatrics 107: 1210-3, 2001.